FORMS & RESOURCES

PATIENT REGISTRATION FORMS

Please complete these forms and bring them to your first appointment.

WOMEN’S HEALTH FORMS

Please complete these forms and bring them to your first appointment.

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

The form must be completed by the patient when they would like a copy of their medical records provided to them or another healthcare provider. This form must also be completed by the patient when giving the Falcon Health Center permission to disclose personal health information for reasons other than treatment, payment or health care operations. There may be a charge for copies.

VERIFICATION OF MEDICATION ORDERS

This form must be completed by a physician for those requiring administration of medication. In addition to a prescription sent to the pharmacy, our physicians will need a doctor’s order from the prescribing physician with information about the last administration. This information can be faxed to our office at 419.354.3222.

 

CHIROPRACTIC INSURANCE BENEFIT QUESTIONNAIRE

In order to provide you with the most accurate information regarding any possible out of pocket expense for the care that you may be receiving from Dr. Mickey Frame, we ask that you please contact your insurance company to confirm that your insurance includes chiropractic care. Please note that this is not a guarantee of your out-of-pocket expense. Please call your insurance company and complete this questionnaire. If you have any questions, please contact our office at 419-728-0601.

 

HIGH SCHOOL PHYSICAL CLINIC FORMS

Please print and complete the following forms and bring to the high school physical clinic. These forms are necessary for the physical to be completed. We will be unable to see any patients that do not have completed forms.

Falcon Health

Falcon Health Center is located next to the Bowling Green State University (BGSU) campus.

The Center serves the entire surrounding community as well as the BGSU faculty, staff and students. Falcon Health Center offers convenience care appointments with medical providers, immunizations, travel medicine, skin screenings, lab and radiology services, acupuncture, chiropractic care and physical therapy. For your convenience the Falcon Health Center offers a full-service pharmacy with drive through.